RN - Clinical Review
Healthcare - Nursing
Queens, New York
- Performs clinical/medical reviews of previously denied cases in which a formal appeals request has been made.
Excellent knowledge of all relevant PACE and applicable Federal and State regulatory requirements and guidelines, knowledge of CenterLight policies and procedures, and individual judgment and experience to assess the appropriateness of services, items provided, length of stay and level of care.
Collects relevant medical information and applies the appropriate evidence-based guidelines and medical policy for denied services associated with appeal cases.
Prepares cases for Medical Director Review or External Physician Advisor ensuring that all pertinent information
- Graduate from an Accredited School of Nursing. Bachelor's degree in Nursing preferred.
- Current Nursing license
- 3-5 years’ clinical nursing experience, with 1-3 years in a managed care healthcare setting with experience clinical practice with experience in appeals & grievances or claims processing
- Knowledgeable about Medicare (CMS) PACE and Medicaid MLTC regulations Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment
Disclosure: The hourly rates and/or salaries listed may or may not reflect total compensation packages including bonus and fringe benefits, etc., nor are the advertisement(s) posted a guarantee of a certain compensation package for a position or bona fide offer of employment. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, or protected veteran status and will not be discriminated against on the basis of disability.